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It's a decade or more since pavement cafes and al fresco dining started to become widespread, The press celebrated this phenomenon, either as an embracing of continental culture or a beneficial side-effect of global warming. At the time, a few chill summers soon got the furniture back indoors. Travel around England in the past 2 or 3 years, though, and every pub you pass has its outdoor tables, umbrellas, and space heaters. It's nothing to do with global warming or that last holiday in the Med, and everything to do with the ban on smoking.
Perhaps living in the North East, where smoking rates are the highest in England and women are 50% more likely to smoke than in London, makes the impact of the ban more evident.1 There is certainly more to it than a suburban sprawling of our legendary ability to dress for midsummer in mid-February. It is remarkable, but the ban on smoking in public places seems to have been absorbed into popular culture. Contrast this with countries such as Spain, where a similar ban was imposed at the same time and is an affront to be ignored or subverted at every turn.
Tackling a public health problem such as smoking requires a multifaceted approach, but population measures and legislative actions seem increasingly to be favoured over those directed at individuals. Indeed the World Health Organization in its Framework Convention for Tobacco Control doesn't include help for individuals in its six key provisions.2 Intuitively, this makes sense. The returns for the UK from a policy based on smoking cessation services have not been impressive.
In general practice we see many people whose health would benefit if they stopped smoking. We have all lost count, for example, of the number of patients with early COPD to whom we have given such advice. To see a patient stop on your advice is a gratifying experience, but often tinged with an uneasy feeling of not being quite sure how you did it or whether it'll work with the next patient. This year's RCGP and Merck, Sharp and Dohme Ltd Research Paper of the Year gives us a useful tool to back up that advice, one that could easily be applied in clinical practice.
Gary Parkes and his colleagues took a formula, first described over 20 years ago, that generates a measure of lung age. Lung age is the age of the average person who has an FEV1 equal to the individual, and is a way of making spirometry results easier for patients to understand. They developed a feasible method of applying it in general practice and then targeted a higher-risk group within the smoking population, those over 35 years of age. Communicating this information to smokers in this age group resulted in an absolute reduction in smoking rate at 12 months of 7.2% (NNT 14), at an estimated cost of £280 per successful quitter.3
This rigorously conducted study showed that the simple intervention of telling smokers their lung age is as effective as, and likely to be cheaper than, the approaches to smoking cessation that are in current use. Why does it work, and in particular why does it work for people with normal as well as abnormal lung age? Parkes offers the observation that some participants were relieved that their results were normal and that it was ‘not too late’ to try to quit. The study was underpowered to relate quitting to Prochaska's ‘stage of change’, but intuitively it seems that something else is going on that can only be fully explained by a different psychological model. But then perhaps on this occasion the mechanism is less important than the effect.